Employee Disability Disclosure Form1

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Employee Disability Disclosure Form1 Powered By Docstoc
					                                               Disability Resource Center
                                         Employee Disability Disclosure Form
The Disability Resource Center (DRC) is the designated University office to assist employees with disabilities. In
order to provide assistance, it is necessary to determine eligibility in a timely manner. Any information you provide is
strictly voluntary.

Please return this form along with proper documentation which explains the current impact and functional limitations
of the disability in accordance with university documentation guidelines found at www.utc.edu/DRC.

Name_____________________________________________ UTC ID Number ____________________________
Address, City, State, Zip___________________________________________________________________________
Contact Number__________________________________________________________________________________
Date of Hire _____________________________________ Department _____________________________________
Consistent with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act-Amendments
Act, it is the policy of The University of Tennessee at Chattanooga that no qualified individual with a disability shall
be excluded from, denied the benefits of, or be subjected to discrimination in any UTC program, service or activity.
1. What is the nature of your disability?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

2. Current impact and functional limitations of disability:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

 3. Accommodations requested:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

Reasonable accommodations are determined individually and are intended to minimize the effects of the impact of
specific limitations caused by a disability in order for a qualified individual to have equal access to programs, services
and activities. Individuals will be contacted regarding their eligibility status.

I give the Disability Resource Center (DRC) permission to consult with medical and mental health professionals, HR
Representatives, and the campus ADA Coordinator at UTC in order to assist the DRC staff with the evaluation of my
medical and/or psychological documentation. I understand that the this information will be kept confidential to the
extent permitted by law.
Signature________________________________________________                             Date____________________________

    The University of Tennessee at Chattanooga is committed to providing equal opportunity in education and
    employment to all applicants, students, and employees. The university does not discriminate in access to its
    educational programs and activities, or with respect to hiring or the terms and conditions of employment, on the basis
    of race, color, national origin, religion, creed, sex, gender identity and expression, political affiliation, age, disability,
    veteran status, or sexual orientation. The university actively promotes diversity among students and employees.

				
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